Abstract

Summary: Keywords: Recovery-oriented mental health services — those in which consumers actively participate in selecting services and developing treatment plans while working toward recovery — are increasingly viewed as more effective and efficient than the traditional medical model. In recent years, national organizations have identified gains made possible by active, engaged consumers of mental health services. Certification programs for peer specialists to learn to provide peer support are an established vehicle for empowering consumers, but many service providers are unsure of how to include peer specialists in their organizations and may be skeptical of their value. This case study describes an employer learning community model for providers and consumers to explore, through a team approach, the value of having consumers in peer specialist roles and the importance of recovery-oriented practice. The peer specialist employer learning community has shown to be a promising method to guide organizations through the process of adopting a recovery model of service provision with certified peer specialists in meaningful, effective roles.Keywords: Mental health; mental illness; peer support; peer specialist; recovery; e-patient; learning communityCitation: Frost L, Heinz T, Bach DH. Promoting recovery-oriented mental health services through a peer specialist employer learning community. J Participat Med. 2011 May 9; 3:e22.Published: May 9, 2011.Competing Interests: Lynda Frost is Director of Planning and Programs at the Hogg Foundation, which provided grant support along with the Texas Department of State Health Services for this project. Evaluation data was collected by independent evaluators. Tammy Heinz is a Program Officer and Consumer & Family Liaison at the Hogg Foundation, which provided grant support along with the Texas Department of State Health Services for this project. Evaluation data was collected by independent evaluators. Dennis H. Bach is the Project Director for Via Hope.

Introduction

The traditional medical model of mental health service delivery in the United States “focuses on the defect or dysfunction within the patient,[1]” using highly trained professionals diagnosing and treating passive service recipients. This model has generated expensive care with moderate results and longstanding shortages within the mental health workforce.[2] Even more challenges exist in accessing quality up-to-date care and the best support services, including a long delay between new scientific discoveries and their use in practice, limited funding and budget reductions, workforce shortages, and the unintentional encouragement of long-term care in mental health treatment.[3]

These results and challenges have led key national groups to call for a full transformation of the system that delivers mental health services in the United States.[2]3][4][5] According to the President’s New Freedom Commission final report, successful transformation rests on services and treatments that are consumer- and family-centered with real and meaningful choices and care that is focused “on increasing consumers’ ability to successfully cope with life’s challenges, on facilitating recovery and on building resilience, not just on managing symptoms.[4]”

Recovery from mental illness is a relatively new concept. A national consensus statement developed by over 110 mental health consumers, family members, providers, advocates, researchers, academicians, managed care representatives, accreditation organization representatives, state and local public officials, and others concluded that “mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.[5]” Recovery-oriented services instill hope that recovery is possible and that mental illness does not have to be lifelong or chronic. They empower consumers to take personal responsibility for their wellness and include consumers in decisions that concern them. They educate consumers that mental illness is only a piece of who they are and consider their individual goals in treatment, rather than simply managing symptoms. They include community outreach to decrease isolation as well as more traditional services (eg, medication management, therapy, crisis hotlines, and employment support), all offered with the belief that recovery is possible.[6] The President’s New Freedom Commission identified recovery as the most important goal of the people served by the system.[5]

For many consumers, an important component of recovery is finding meaning and significance in their personal experience with mental illness. Often, consumers find a fulfilling role in the provision of support to their peers in natural or formal settings.[7] The incorporation of peer specialists, ie, individuals who self-identify as persons in recovery from mental health issues and are trained to work with fellow consumers by providing education, advocacy and support,[2][4][5][8] empowers consumers of mental health services and is a crucial component of a recovery orientation.[9]

Limited numbers of peers have worked in paid positions with mental health providers for several decades.[9][10][11][12] Their roles have varied, ranging from advocate to peer counselor, treatment team member, support group leader, educator, personal coach, resource navigator, or evaluator.[13][14[15][16] They faced barriers from colleagues such as lack of trust, exclusion, role confusion, lack of respect, and fear of their fragility in terms of workload.[13][14[17 They also faced personal challenges such as isolation, dual relationships, low pay, and lack of a career ladder.[13][17[18][9]

Preliminary research on peer support was mostly qualitative and anecdotal, but it indicated that the approach was feasible.([19] Random controlled trials of peer support for adults with depression showed superior results when compared to usual care alone and comparable results to group cognitive behavioral therapy.[20] Gradually, the role of peer specialists has become more widely accepted in the mental health community.[21] Over the last decade, states and providers have identified funding sources, especially Medicaid, for many peer support services.[22] This led to an increase in the number of training programs leading to certification as a peer specialist and higher demand for peer support services.[21]

Today, in a departure from traditional mental health services, certified peer specialists play an essential role in some service environments. While certified peer specialists’ job descriptions are dependent on the environment in which they are employed (eg, state hospitals, community mental health centers, and consumer-run clubhouses), their approach entails a new and more participatory role for consumers in their own treatment goals and services, as well as the opportunity to advocate for and support their peers.[23] A primary difference in approach is that in addition to traditional knowledge and competencies, peer specialists use their lived experience and experiential knowledge.[12][24] A certified peer specialist lives recovery, often using language based upon common experience rather than clinical terminology ([19] The use of peer specialists as part of the treatment team has been shown to have favorable results.[18][25] Often, information that peers obtain during peer support is viewed as more credible than that obtained by mental health professionals.[26] When peers are part of hospital-based care, the “results indicate shortened lengths of stays, decreased frequency of admissions, and a subsequent reduction in overall treatment costs” ([3]). Other studies suggest that using peer support can reduce the long-term need for mental health services.[3][27][28]

This case study describes the evolution of a statewide employer learning community for employers of peer specialists in Texas and the experiences of participating service providers. It summarizes outcomes from the first-year employer learning community and resulting changes made for the second-year employer learning community. It traces the evolution of consumer roles during this process and describes how, in order for consumers to be active participants in their recovery, service providers must shift their culture from a traditional medical model to a recovery-oriented focus. It concludes that a process dedicated to this shift, like the employer learning communities implemented in Texas, can facilitate a faster and more successful change.

Case Study

In 2008, the Texas Department of State Health Services and the Hogg Foundation for Mental Health identified strategies to move the mental health system in Texas toward a transformed system, including recovery-oriented services. Their goal was to address the most significant challenge in the mental health system identified by the Substance Abuse and Mental Health Services Administration — the lack of orientation to the hope of recovery — as well as to address workforce shortages, budget reductions, and limited access to care.

One strategy was to increase the number of peer specialists working in mental health settings to provide recovery-oriented services and serve as living models of recovery. States that had already identified and implemented this strategy recognized the need for training and certification programs in order to legitimize and professionalize the peer specialist role and set core competencies for practice.[22]

Via Hope Peer Specialist Training & Certification

In 2009, the Department of State Health Services (later joined by the Hogg Foundation) funded Via Hope, a training and technical assistance center for Texas mental health consumers, youth, family members, and professionals. Via Hope is responsible for developing a training and certification program for peer specialists, facilitating the development of a statewide consumer network and coordinating educational opportunities for consumers, family members and professionals. Via Hope is a collaboration of the Department of State Health Services, the Hogg Foundation, Mental Health America of Texas, and the National Alliance on Mental Illness-Texas.

Via Hope’s peer specialist training requires 40 hours over five days and covers topics such as five stages in the recovery process, the role of peer support in recovery, effective listening, ethics, and the relationship between mental and physical health (ie, whole health). The curriculum is structured to train Texas peer specialists in skills and content universal to peer support issues in a variety of settings and models as well as to provide an understanding of the resources and systems unique to Texas. At the end of the 40-hour training, the peer specialists are required to pass a written exam in order to be certified.

Through the training and certification program, Via Hope has trained 136 individuals as peer specialists and certified 116 as of February 2011. Most of the participants were employed as peer specialists prior to attending the training, but had not had formal training. The program established statewide professional standards for peer specialists by setting core competencies for their practice. While the overall number of peer specialists in the state has not increased dramatically, their overall competency increased.[29]

Once Via Hope began offering certification classes, it discovered strong consumer interest in becoming trained and certified[29] While developing the program, Via Hope identified a need to ensure that employment opportunities existed for newly trained peer specialists. A concern was that certifying dozens of new peer specialists each year could saturate the market before sufficient mental health providers offered this service as a treatment option for their clients. Via Hope thus began an outreach program to local mental health centers to pave the way for the creation of peer specialist positions in their organizations[29]

The Peer Specialist Employer Learning Community

Late in 2009, Via Hope launched a peer specialist employer learning community, hereafter identified as the “employer learning community.” The purpose of the employer learning community was to encourage member organizations to hire self-identified consumers trained and certified in peer support skills to serve their clients. Via Hope invited all 38 local mental health authorities in Texas to apply to participate in the first employer learning community, where they would receive guidance and support in developing a peer specialist program and successfully incorporating it into their ongoing operations. The clear intent was for the member organizations to hire new peer specialists or enhance and expand the use of current peer specialists.

The applicants were expected to designate an executive sponsor, someone with the ability to implement any changes identified during the employer learning community process. This executive sponsor was required to sign the application and confirm the organization’s commitment to the employer learning community. The provider applicants could identify up to four members to represent their organization in the employer learning community. These four members could be any combination of clinical staff, administrative staff, or consumers, but there had to be at least one consumer member. All accepted organizations were required to:

Conduct an anonymous online recovery self-assessment staff survey immediately following notice of acceptance for their organization;

Participate in a three-day kick-off conference that included a program orientation and workshops to begin developing their implementation plan;

Encourage peer specialists currently working in the centers to apply for the certified peer specialist training (peers associated with the employer learning community member organizations were given acceptance priority);

Participate in monthly conference calls and webinars with other teams to share progress and experiences;

Conduct a follow-up anonymous online recovery self-assessment staff survey six months after the kick-off conference; and

Attend a second implementation (wrap-up) conference in the summer of 2010 to share their experiences with other teams and provide an example for other centers that are interested in beginning the program.

Eleven community mental health centers and one consumer-operated service provider participated in the first employer learning community, which lasted nine months. Employer learning community member organizations received financial assistance to offset most of the travel and lodging costs for participants to attend the kick-off and wrap-up conferences. They also had access to technical assistance including an implementation toolkit (including the readiness assessment and staff survey) to help plan and develop their program, workshops led by nationally recognized experts in the use of peer specialists, facilitated monthly conference calls and webinars, and an online forum where team members could exchange information and ask questions.

During the first employer learning community, Via Hope identified a need for further instruction on the nature of a recovery environment and how to create one. It offered to provide a nationally recognized expert in recovery and peer services to hold a one-day, on-site training for staff. Seven of the twelve participant organizations requested and received the training.

Results

Via Hope contracted with a team of researchers at the University of Texas at Austin Center for Social Work Research to provide an evaluation of the peer specialist training and certification program. The evaluation[29] had two primary goals:

“[D]ocument stakeholder feedback on the factors related to the successful development and implementation of a peer specialist training and certification program in Texas…, and

[E]xplore the experience of individual participants (i.e., program completion, potential personal and vocational gains) related to completion of the training and/ or certification process”

Data collection for the evaluation included an online survey of knowledge and attitudes related to peer support training and recovery orientation in Texas; a recovery self-assessment survey; observational notes from training events, conference calls, and program meetings; applications submitted to Via Hope for the peer specialist training courses; daily evaluations forms and satisfaction surveys collected by Via Hope during the peer specialist training courses; certification exams; and training pre- and post-tests.

The evaluation concluded that the first employer learning community was a successful strategy, stating that one of the 12 participating member organizations created peer specialist positions in its organization; five participants enhanced peer support programs, and six expanded peer specialist positions.[30]

Stakeholder feedback from project staff and individual trainees related to the first evaluation goal was obtained through an online survey of knowledge and attitudes administered every three months over the course of nine months. Respondents praised the flexibility of the curriculum across different settings and individual needs. They suggested a number of improvements to the program, noting the need for a system-wide culture shift toward a recovery-oriented practice; instruction on how to integrate and support certified peer specialists in their positions; an increased emphasis on skill building in the curriculum; training and support for certified peer specialists as they implement peer services and maintain fidelity to the evidence-based practice of peer support without compromising their positions; development of certified peer specialist positions statewide; follow-up after certification to support certified peer specialists’ ongoing professional development and success; and a reimbursement billing code specifically for the services provided by certified peer specialists in the State Medicaid Plan.[29]

Data relevant to the second evaluation goal about individual participants showed that all participants were working as peer specialists and that the majority of those positions were paid. Respondents reported confidence in their abilities and satisfaction with their jobs. The peer specialists scored high in the adoption of a recovery-orientation.[29] But results from the recovery self-assessment survey taken by the participating member organizations’ staff showed that for a broader group over a six-month period, the overall assessment average increased marginally, potentially indicating a modest positive impact on the member organizations’ recovery orientation.[29] The evaluation concluded that although including peers in the mental health workforce has an effect on agency staff, this is not enough to provide the culture shift necessary to completely move to a recovery-oriented practice.[30]

The evaluation report recommended adjustments for a second employer learning community scheduled to launch immediately after the end of the first employer learning community. One of the strongest recommendations from the evaluators was to shift the second employer learning community to be “recovery focused with the integration of peer specialists included as part of that change rather than the focus of the change.[30]” The evaluators also suggested that the executive sponsors be required to participate more fully in the second employer learning community. Because the sponsors were only required to sign and submit the application in the first employer learning community, their attendance and investment was quite varied. Many never participated after the initial application process.

Reflecting on the evaluation, Via Hope made core changes to the second employer learning community, launched in late 2010. It shifted the focus of the second employer learning community and addressed peer support services as one of the major components of a recovery-focused organizational culture. Many of the requirements and intended benefits to participating organizations were the same in the second year, but the executive sponsors were required to attend the kick-off conference and continue participating in the ongoing work of the change teams from the member organizations. The nationally recognized faculty from the kick-off conference were made available for technical assistance to member organizations following the event. More data collection and ongoing feedback and support were added. In addition, the on-site trainings were made standard for all member organizations and were conducted earlier in the process. Fifteen organizations participated; 10 were community mental health centers and five were state hospitals. The second employer learning community is scheduled to last ten months, ending in September 2011.

Discussion

During the first year of the peer specialist learning community, Via Hope staff recognized the need for recovery education and consultation in many of the member organizations. As they received feedback from certified peer specialists returning to their unchanged organizations and discussed their organizational culture one-on-one with the member participants, it became obvious that without an orientation toward recovery, the organization was less likely to see the value in the certified peer specialist role. Via Hope then provided additional recovery education and consultation to these organizations so they could offer the greatest chance of success to the certified peer specialists. This evolution is consistent with research indicating that for an organization to integrate certified peer specialists most effectively, a recovery orientation is crucial.[31] Providers must be convinced that recovery can and does happen in order to start sharing that concept with other consumers.[9]

The shift in orientation from the first employer learning community to the second essentially moved from adding peer support specialists into existing service delivery models to adopting a recovery-oriented service model in which peer support specialists play an important role. In classic organizational change theory,[32] the initial employer learning community focused on first-order change that helps the organization do what it is already doing in a better way. The second employer learning community was designed to promote second-order change, which requires a paradigm shift by redefining the way business is done. Using these descriptors, Via Hope initially attempted to encourage the member organizations to make a first-order change by hiring certified peer specialists but later realized that in order for that to be a successful goal, a second-order change was required, a culture shift to a recovery orientation.

Adopting a more contemporary analysis from the field of healthcare reform,[33] at first Via Hope approached peer support as a sustaining innovation, improving mental health service provision by integrating a useful tool into the existing system. As a result of feedback and challenges, Via Hope came to view peer support as a disruptive innovation that comes from outside to transform a traditional system and better address longstanding inefficiencies through a more accessible and effective service model based on recovery and hope.

It is too early in the process to gauge the effectiveness of the second, recovery-oriented employer learning community. It is clear that systems change of this type requires significant time and effort. But research indicates that peer support services can improve outcomes and that peer support specialists do best in a recovery-oriented environment.

Conclusion

Traditionally, mental health services have resembled medical services in their unidirectional approach and lack of interactive communication. In recent years, national organizations have recognized the significant gains possible through the development of more active, engaged mental health service consumers. Certified peer specialists are an established vehicle for empowering consumers, but many service providers are unclear how to include certified peer specialists in their organization and even may be skeptical as to their value. A learning community for providers can be a promising tool to guide organizations through the process of adopting a recovery model of service provision with certified peer specialists in meaningful, effective roles.

Wow – what a comprehensive look at recovery and peer services and the ways they are intersecting the mental health system. A great outline of the status of recovery, as well as the systems change that guides providers to utilize certified peer specialists in more complete and meaningful ways.

Since writing the book “Crazy: A Father’s search through America’s Mental Health Madness” journalist Pete Earley has become a fierce advocate for improving mental health care.

Recently his son Kevin wrote a post about his recovery process and his work as a peer specialist. His story truly reflects empowerment strategies in recovery from symptoms of severe mental illness.

“…It is challenging work, especially when I deal with consumers who are as hard to reach today as I was during low points in my past, but I cannot explain how rewarding it is when I do reach someone, when I do make a difference and impact the course of another person’s life… I feel that I have finally found my professional calling, and every day I am joyous that I am able to serve others in such a capacity.”

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